A study on the usefullness of pediatric appendicitis scoring system in the diagnosis of acute appendicitis

SCORING SYSTEM IN THE DIAGNOSIS OF ACUTE APPENDICITIS.

Dissertation

Submitted in partial fulfillment of the regulations of

M.S. DEGREE EXAMINATION

BRANCH I GENERAL SURGERY

THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY

CHENNAI

This is to certify that this dissertation titled “A STUDY ON THE USEFULLNESS OF PEDIATRIC APPENDICITIS SCORING SYSTEM IN THE DIAGNOSIS OF ACUTE APPENDICITIS.” is the bonafide work done by Dr. SATHYANARAYANAN M., Post Graduate student (2011 – 2014) in the Department of General Surgery, Government Stanley Medical College and Hospital, Chennai under my direct guidance and supervision, in partial fulfillment of the regulations of The Tamil Nadu Dr. M.G.R Medical University, Chennai for the award of M.S., Degree (General Surgery) Branch - I, Examination to be held in April 2014.

Prof.T.S..JAYASHREE, M.S.,D.G.O Prof. K. KAMARAJ, M.S.,

Professor of Surgery, Professor and Head of surgery, Dept. of General Surgery, Dept. of General Surgery, Stanley Medical College, Stanley Medical College, Chennai-600001.

PROF. S. GEETHA LAKSHMI, M.D., PhD,

The Dean,

I, DR.M.SATHYANARAYANAN solemnly declare that this dissertation titled “A STUDY ON THE USEFULLNESS OF PEDIATRIC APPENDICITIS SCORING SYSTEM IN THE DIAGNOSIS OF ACUTE APPENDICITIS “ is a bonafide work done by me in the Department of General Surgery, Government Stanley Medical College and Hospital, Chennai under the guidance and supervision of my unit chief.

Prof.T.S..JAYASHREE, M.S.,D.G.O Professor of Surgery

This dissertation is submitted to The Tamilnadu Dr. M.G.R. Medical University, Chennai in partial fulfillment of the university regulations for the award of M.S., Degree (General Surgery) Branch - I, Examination to be held in April 2014.

Place: Chennai.

I am highly indebted to my guide Prof. T.S.JAYASHREE, M.S. D.G.O., Professor of Surgery for her constant help, inspiration and valuable advice in preparing this dissertation.

I express my deepest sense of thankfulness to my Assistant Professors Dr. DORAI, M.S. D.Ortho., and Dr. CHITRA M.S., D.G.O.,

for their valuable inputs and constant encouragement without which this dissertation could not have been completed.

I consider it a privilege to have done this study under the supervision of my beloved Professor and Head of the Department

Prof.K. KAMARAJ, who has been a source of constant inspiration and encouragement to accomplish this work.

I express my sincere gratitude to my mentor Prof. P. DARWIN, former Head of Department of General Surgery. I thank him for the constant support, able guidance, inspiring words and valuable help he rendered to me during my course.

I am grateful to the Dean Prof. S. GEETHALAKSHMI for permitting me to conduct the study and use the resources of the College.

It is my earnest duty to thank my parents, wife and friends

without whom accomplishing this task would have been impossible.

Acute appendicitis is the most common surgical emergency worldwide. If not detected early

and treated, it can lead to perforation, peritonitis,& abscess formation. Despite many advances in

imaging modalities, the diagnosis of this condition is essentially clinical. In children, because of poor

development of omentum, the rate of perforation is high. Hence to detect this condition early and

to reduce the rate of negative appendicitis in children, many scoring systems have been developed.

Our study deals with the PEDIATRIC APPENDICITIS SCORING SYSTEM by ,Madhan Samuel. In this

study, about 50 children between the age group 4-15 years of age presenting with acute abdominal

pain to Govt Stanley Medical College were selected and PAS was applied. Each of them were

assigned a score based on 8 variables to a total score of 10.They were into 3 groups those with >8

were taken up for surgery, <4 were discharged and those with scores 5-7 were subjected to imaging

and taken up for surgery if proven by imaging. The groups were compared and the sensitivity of the

test was 97%, specificity was 85 % and positive predictive value was comparable to the original

study. The study showed that PAS can be used as adiagnostic tool in the diagnosis of acute

S. NO. CHAPTER PAGE NO

1. INTRODUCTION 01

2. AIMS AND OBJECTIVES 03

3. REVIEW OF LITERATURE 04

4. MATERIALS & METHODS 64

5. OBSERVATION AND RESULTS 67

6. DISCUSSION 73

7. CONCLUSION 75

8. BIBLIOGRAPHY

9. ANNEXURE

(i) PROFORMA

(ii) MASTER CHART

(iii) INSTITUTIONAL ETHICAL COMMITTEE APPROVAL CERTIFICATE

(iv) CONSENT FORM

INTRODUCTION:

Appendicitis refers to inflammation of the appendix due to 3to

various etiologies and is the most common general surgical emergency

worldwide. Acutely inflamed appendix can be removed surgically either

by laparoscopic or open technique and is the most commonly performed

emergency general surgical procedure. But the diagnosis of acute

appendicitis can be difficult and challenging in certain circumstances.

Though there have been many advances in imaging diagnostic modalities

the diagnosis of acute appendicitis is essentially clinical. Hence various

clinical scoring systems have been developed to diagnose or exclude

appendicitis. Delaying intervention in acute appendicitis or failure to

diagnose at the earliest can result in severe complications especially in

children and elderly. The incidence is about 8% and is common between

ages 10 to 30 with male: female ratio of 1.8:1[1].

Though there are several scoring systems in the adult for diagnosis

of appendicitis the sensitivity and specificity of such scoring system drops

when applied to children due to differences in clinical presentation. Hence

several pediatric appendicitis scoring systems have been developed to

early but is also cost effective and avoids indiscriminate use of imaging

studies in children.

Of these the most commonly used scoring system is the

PEDIATRIC APPENDICITIS SCORING SYSTEM developed by

MADHAN SAMUEL. There are 8 variables that are used to clinically

score and categorize children into 3 categories upon a total score of 10;

namely, those with scores less than 3, and those with 4 to 6 and those with

7 to 10. Those children with scores over 7 had a high probability of

appendicitis and subsequently were taken up for surgery. Those with

scores less than 3 were discharged and subsequently followed up as

out-patients. Those with scores with 4 to 6 were subjected to further imaging

studies and were followed up as in-patients till pain is relieved or another

AIMS AND OBJECTIVES:

To study the usefulness of PEDIATRIC APPENDICITIS SCORE

in the diagnosis of acute appendicitis in children by correlating the clinical

diagnosis obtained by scoring system with intra-operative findings and

REVIEW OF LITERATURE

Berengarius Carpus a professor of surgery at Pavia was the first to describe

vermiform appendix in 1522.

Clado described a fold of peritoneum running from the ovary to the meso

appendix, and since then known as Clado’s ligament.

Reginald Fitz was the first one to coin the term appendicitis.

McBurney in 1889 described his classical sign- tenderness at the point of

two-third and one third junction of the line drawn from umbilicus to

anterior superior iliac spine in acute appendicitis.

Claudius Amyand was the first to remove the appendix in 1735 in a

hernia surgery.

McBurney described his original muscle splitting operation in 1893 and

this was modified by Weir in 1900.

ANATOMY OF THE APPENDIX AND ITS SIGNIFICANCE

The appendix is a derivative of midgut and arises from the cecum as

a small outpouching that gradually elongates into a worm-like tubular

organ.

The cecal diverticulum appears in 6th week of gestation and is the

primordium for both the cecum and the vermiform appendix.

The diverticulum appears as a conical pouch on the antimesenteric

border of the caudal limb of the midgut loop and descends from above.

The distal end of the blind sac retards in growth, thus the appendix-a

vestige of the incomplete development of the cecum, develops.

During the elongation of the proximal colon, the cecum and the

appendix descend from the right upper quadrant of the abdomen to its

The base of the appendix shifts medially during growth due to

excessive growth of right and anterior walls of the cecum.Failure of such

GROSS ANATOMY :

Verminform appendix is a tubular worm-like organ arising from the

cecum. Average human appendix measures 2 to 20 cm in length. The

diameter of the appendix is about 7-8mm. The largest appendix ever

removed measured 26 cm in length from a patient in Crotia.

RELATIONS:

The appendix is related posteriorly to the ilio-psoas muscle and lumbar

plexus of nerves.

Anteriorly its related to the abdominal wall, greater omentum and coils of

intestine.

In cadaver the apex is found medial to mid-point of right inguinal

ligament.

In living individuals the position varies with posture, state of distension of

bowel, muscle tone, and respiration.

In upright posture the cecum and appendix overhangs the pelvic brim.

The tip of the appendix can point toward any organ except toward the

The vermiform appendix has;

1.base attached to the cecum

2. body

3. tip, and

4.a mesoappendix through which the blood supply is derived.

The position of the base is fairly constant in location at about 2cm below

the ileo-cecal valve, but the tip of the appendix is highly variable in

position

BLOOD SUPPLY:

There are 4 patterns of arterial supply for the appendix, namely.,

1.single appendicular artery

2.paired appendicular arteries

3.arterial loop from the anterior cecal,posterior cecal, and ileo-colic

arteries forming accessory appendiceal arteries.

4.anterior and posterior appendicular arteries supplying from the base .Of

Another artery called the artery of Sheshachalam which is a branch

of posterior cecal artery also supplies the appendix.

Veins from the appendix drain into the ileo-colic vein which in turn

drain into the superior mesentric vein

NERVE SUPPLY:

Its innervated by the vagus nerve for parasympathetic supply and the

LYMPHATIC SUPPLY:

Lymphatics drain into the ileo-colic lymph nodes.

These ileo-colic nodes further drain into superior mesentric to the celiac

nodes and finally cisterna chyli.

The lymphatic drainage of the wall of the appendix drains into the lumen

and is different from the lymphatic drainage of the organ.

There is a secondary lymphatic drainage as described byBraithwaite with

the nodes draining into the sub-pyloric nodes anterior to the pancreas.

TOPOGRAPHY OF APPENDIX AND ITS VARIOUS POSITIONS:

In malrotation of the midgut the appendix may be found in the left

iliac fossa resulting in pain in that region in acute appendicitis.In old age

people, the appendix may become cord-like and very rarely the appendix

may be altogether absent.

The location of the appendix can be anywhere from its initial

position in the right upper quadrant of the abdomen in utero to its final

location in the right iliac fossa which is the most common location for the

Also the position of the tip is highly variable and its unusual

position can pose difficulties in diagnosis of appendicitis and also during

surgical removal.

The most common location for the appendix is retrocecal followed

by pelvic position.the following are the percentage of various positions of

the appendix.

Retrocecal-64%

Pelvic -32%

Sub-cecal-2%

Pre-ileal-1% Post-ileal-0.5%

HISTOLOGY:

The appendix histologically has four layers – mucosa, sub-mucosa,

an inner circular and an outer longitudinal muscle layer and a serosa. The

appendicular lumen is stellate in cross-section.

The mucosa of the appendix is rich in mucinous glands and crypts.

The mucosa also contains neuro-endocrine cells , histiocytes and

eosiniphilic cells.

The base of the crypts contain paneth cells with basal nuclues,

conspicuos nucleoli and abundant eosinophilic cytoplasm.

The appendix is essentially a lymphoid rich organ with abundant

lymphoid follicles in its lamina propria – functionally part of the gut

associated lymphoid tissue.These lymphoid follicles get inflammed and

when they do so they can cause acute appendicitis.They are abundant in

Histology of normal appendix

This picture shows mucosa and submucosa and muscularis externa

layers with lymphoid collicles in the lamina propria. The mucosa also

The altered histology in appendicitis

Picture shows epithelial sloughing and extensive neutrophil infiltration of the mucosal and sub-mucosal layer with protein-rich

PATHOPHYSIOLOGY OF ACUTE APPENDICITIS

There are basically two major types of pathological processes involved in

acute appendicitis.

1. obstructive type,

2. non-obstructive type(acute catarrhal).

1.

Obstructive type

The major cause of acute appendicitis is the obstruction of the

appendiceal lumen. This is due to

1. inspissated stool (fecalith or appendicolith),

2. lymphoid hyperplasia,

3. vegetable matter or seeds,

4. worms- Balantidinum coli, Enterobius vermicularis, Schistosomia

hematobium

5. barium from previous contrast studies.

6. a neoplasm.

The lumen of the appendix is very small with respect to its length,

Obstruction of the lumen causes bacterial overgrowth, and

continuous secretion of mucus by mucinous cells.

This leads to distention of lumen and increase in transmural

pressure.

This distension causes visceral pain experienced by the patient as

periumbilical pain.

Resulting impaired lymphatic and venous drainage causes mucosal

ischemia.

These process combine to cause a localized inflammatory process

which progresses to gangrene and perforation.

Inflammation of the adjacent parietal peritoneum causes localized

pain in the right iliac fossa.

Usually , perforation typically occurs after 48 hours from the onset

of pain and is followed by formation of an abscess cavity .

This abscess cavity is walled-off by small intestine and omentum.

Sometimes , free perforation of the appendix into the peritoneal

cavity may result in peritonitis and peritoneal sepsis.This may

complicate as multiple intra-abdominal abscesses.Sometimes even

Factors encouraging Progression of Inflammation:

(i) Very young or old age.

(ii) Immunosupression.

(iii) Free lying appendix.

(iv) Presence of faecolith.

(v) Purgatives.

(vi) Impaired blood supply.

2.NON-OBSTRUCTIVE TYPE:

In this type, the inflammation commences either at the mucous membrane

of the appendix or in the lymph follicles and terminates either as

1. resolution,

2.ulceration

3. suppuration

4.fibrosis or

5. gangrene.

The infection progresses rapidly once it reaches the submucousal

The organ becomes inflammed, turgid, dusky red and haemorrhage

into the mucous membrane occurs. The distal part of the appendix is often

prone to ischaemia as the artery is intramural and is liable to occlusion by

inflammation and thrombosis thereby, leading to gangrene of the tip of the

appendix.

The non-obstructive type progresses slowly and a protective barrier

is formed and the inflammation does not progress beyond the mucosal

lining and the attack wanes off without sequelae.This is known as acute

catarrhal appendicitis.

But this catarrhal type is notorious to recur causing frequent attacks

many a times a year in few cases. In that case an elective or emergency

appendectomy has to be planned otherwise it may result in chronic

recurring pain.

CHRONIC APPENDICITIS: This is condition of gradual inflammation of

the appendix leading to frequent episodes of right lower quadrant pain.The

clinical features are milder than acute appendicitis but usually complete

Bacteriology of appendicitis:

The normal appendix contains flora that is very similar to that of the

colon.

It contains both facultative aerobic and anaerobic bacteria. Thus the

cultures in perforated appendicitis is polymicrobial in nature, namely,

1. Bacteroides

2. Pseudomonas

3. E.coli

4. Streptococcus viridians species

In patients with acute non-perforated appendicitis, cultures from

peritoneal fluid are frequently negative.

But in patients with peritoneal contamination due to perforation,

cultures are frequently positive with adequate sensitivity to antibiotics for

proper selection of anti-biotics in post-operative period.

Also the virulence of these organisms in extreme enough to cause

Bacteria Commonly Isolated in Perforated Appendicitis

ANAEROBIC PATIENTS (%)

Bacteroides fragilis 80

Bacteroides thetaiotaomicron 61

Bilophila wadsworthia 55

Peptostreptococcusspecies 46

AEROBIC

Escherichia coli 77

Streptococcus viridians 43

Group D streptococcus 27

CLINICAL FEATURES:

HISTORY

Appendicitis should be considered as a differential diagnosis in

almost every patient with acute abdominal pain. Early diagnosis is

important in patients with suspected appendicitis and can usually be made

on the basis of history and physical exam. The typical presentation is an

adolescent male or female with periumbilical pain followed by anorexia,

nausea and vomiting.

The pain then localizes to right iliac fossa as the inflammation

progresses to involve the parietal peritoneum overlying the appendix. This

is a classic pattern of acute appendicitis.

This migratory pain is the most reliable symptom of acute

appendicitis but the symptom is not always present.

The patient may have a bout of vomiting. This is in contrast to

repeated bouts of vomiting that occurs in viral gastroenteritis or intestinal

obstruction. Fever ensues, followed by leukocytosis.

But clinical features may vary. The classic triad of pain followed by

Rarely, patients may have urinary symptoms or microscopic

hematuria, owing to the inflammation of periappendiceal tissues that are

adjacent to the ureter or bladder, and this may be mislead one to consider

ureteric colic as the first in differential diagnoses.

Most patients with appendicitis develop an adynamic ileus and absent

bowel movements, but occasional patients may present with diarrhea.

Some may present with acute small bowel obstruction due to contiguous

regional inflammation and adhesion.

Therefore, appendicitis can be a possible cause of small bowel

obstruction, especially in patients without prior history of abdominal

surgery.

ATYPICAL PRESENTATIONS:

The position of the tip of the appendix can also result in a myriad of

different presentations.

1.Right hypochondrial pain- pulled up cecum or cecum that had arrested in

its path of descent.

2.Diarrheoa- pre and post-ileal type

4.urinary frequency- retro-cecal type of appendicitis with peri-appendiceal

inflammation.

PHYSICAL EXAMINATION :

Acute appendicitis patients typically have a sick look and lie still in bed.

Usually it is accompanied by a low-grade fever ( 38°C) .

Local Examination of the abdomen reveals diminished bowel sounds and

tenderness at the right lower quadrant with guarding.

The exact site of tenderness is most commonly at McBurney's point –

which is at one third of the distance along a line drawn from the anterior

superior iliac spine to the umbilicus-this point is directly over the

appendix.

The normal appendix is a mobile organ, so it may become inflamed at a

point anywhere on a 360-degree circle about the base of the cecum. Hence,

the site of maximal point of tenderness may vary.

Peritoneal irritation is elicited by the findings of guarding on percussion,

or rebound tenderness.

The following signs may be

2. Rovsing's sign- pain in the right iliac fossa on palpation of the left iliac fossa.

3. Obturator sign -pain on internal rotation of the hip in case of a

pelvic appendix.

4. Cope’s ilio-psoas test- pain on extension of right hip in a retro-cecal

appendix.

5. Digital rectal examination- If the appendix is located within the

pelvis tenderness on palpation of the abdomen is minimal, but

anterior tenderness may be elicited during digital rectal examination

on manipulation of pelvic peritoneum.

6. Per-vaginal examination- movement of the cervix may cause

tenderness in a pelvic appendix.

7. In perforated appendicitis- the abdominal pain intensifies and is

more diffuse. Abdominal wall muscle spasm increases causing

rigidity. Tachycardia with fever may ensue. The patient appears ill

and is briefly resuscitated with fluid and antibiotics are

administered.

Sometimes pain may improve slightly after rupture of the appendix

LABORATORY INVESTIGATIONS:

The following findings are noted:

1. Leucocytosis- a WBC count of more than 20000 is indicative of

perforated or gangrenous appendicitis.

2. Neutrophilia .

3. Microscopic hematuria

4. Pyuria –in case of ureteric involvement in retro-cecal appendix.

5. C-REACTIVE PROTEIN- elevated levels in a patient with clinical

IMAGING:

X-Ray

findings-In 10-15% of patients a calcified appendicolith may be seen.

In barium enema, failure of the appendix to fill with contrast is a sign of

appendicitis. Upto 20% of normal appendix also does not fill with contrast.

ULTRASONOGRAM-1. Sensitivity -85 %

2. Specificity-90%

POSITIVE FINDINGS in favour of acute appendicitis include;

1. Antero-posterior diameter of the appendix >7mm.

2. Target lesion- a thick-walled, dilated non-compressible, aperistaltic

structure.

3. Appendicolith

4. In appendicular mass,peri-appendiceal fluid collection or mass

formation may be seen.

5. RING of FIRE APPEARANCE- increased flow in case of inflamed

ADVANTAGES-1. Non-invasive

2. No radiation-may be used in children and pregnant females.3.Color

Doppler studies can be done to establish gangrenous appendix.

DISADVANTAGES

-1.Operator dependant

2.In 10-15% of cases, appendix may not be detected.

Hypervascularity of appendix in acute appendicitis

This is well seen in color Doppler USG. The incresded flow appears in

Obliteration of fat plane in the psoas region- psoas sign , a feature of

ULTRASONOGRAM of the abdomen showing inflamed appendix as a aperistaltic, dilated loop –longitudinal view

‘Ring of fire appearance’ in color Doppler in transverse view

This is the diagnostic sign in Doppler USG. This is due to extensive

inflammation and increased flow in peri-appendiceal vesssels and

Appendicular mass in Ultrasonogram

Hetoroechoic mass in the right iliac fossa formed by inflamed

appendix, small bowel, omentum with fluid collectin and abscess

COMPUTED

TOMOGRAHY-Sensitivity- 90%

Specificity -80 to 90%.

Positive predictive value- 75%.

CT findings

include-1. Thickened dilated appendix with diameter more than 7 mm.

2. Target sign-circumferential wall thickening appearing as a halo on CT.

3. Peri-appendiceal fat stranding

4. Appendicular abscess

5. Phlegmon

Target sign in CT

Intense contrast-enhancing appendicular wall in appendicitis. This is

due to hypervascularity and venous congestion and increase in

Appendicolith in CT

Appendicoliths may vary in size and number and appear as

Appendicular mass in contast CT.

Hyperattenuated mass in RIF in contrast CT with peri-appendiceal

DIAGNOSTIC LAPAROSCOPY

Most patients with acute appendicitis can be accurately diagnosed

based on history, clinical exam, laboratory studies, and, imaging, but in

some patients the diagnosis still remains elusive.

For these patients, diagnostic laparoscopy can be of certain value.

D-lap can aid in complete survey of the abdominal organs for other

possible causes of pain.

This technique can be used primarily for women of childbearing age

in whom preoperative pelvic ultrasound or CT scan fails to provide a

diagnosis.

Concerns about the possible adverse effects of a missed perforation

and peritonitis on future fertility sometimes prompt earlier intervention in

this patient population.

The diagnostic laparoscopy can also be therapeutic and

appendectomy is done as a routine if no other alternate pathology is

noted.Other pelvic pathologies that can mimic appendicitis are ovarian

cyst, ectopic pregnancy,meckels diverticulum and mesenteric

DIFFERENTIAL DIAGNOSES:

1.

INFANTS-a. Intussusception- this is a common condition in children and

ileocecal intussusceptions can sometimes mimic perforated

appendicitis. Currant jelly stools. But a palpable mass in right

hypochondrium and emptiness in right lower quadrant (dance sign)

are the key features.

b. Hirshprung ‘s disease

c. Cystic fibrosis

2. PRE-SCHOOL

CHILDREN-a. Acute gastro-enteritis- this presents as diarrhea, vomiting and fever.

The abdomen pain is colicky and periumblical but it can be diffuse

and is often a close differential diagnosis.

b. Intussusception- has colicky intermittent abdominal pain, and

positive Dance sign (Emptiness in right iliac fossa)

c. Meckel’s diverticulitis- pain is typically in the periumblical region

and does not have specific radiation, may have associated diarrhea

d. Mesentric lymphadenitis- this is too common in pre-school children

and is usually secondary to upper respiratory tract infection or

gastro-intestinal tract infection.

3. MALES

a. Pyelonephritis:

- this is an inflammation of the renal parenchyma and pelvis due to

bacteria and variety of other causes.

-Pain is mostly in the flanks.

-Associated with fever and leucocytosis.

-Patient looks toxic and obtunded.

-On lab investigations- pyuria may be seen in urine analysis.

-Non –contrast helical CT is the investigation of choice. It may

detect radio-opague stones and obstructed and dilated pelvi-calyceal

system.

-Urine culture demonstrates organisms

-Treatment- i.v. anti-biotics , hydration, and surgical intervention

b.

-this is inflammation of the colon and secondary to infections or

inflammatory bowel disease, auto-immune, and variety of other causes .

-Symptoms are usually diarrhea and cramping right or left-sided

abdominal pain with tenesmus,bloating, loss or appetite at times.

- treatment is usually antibiotics and treating the cause.

c. Ureteric colic:

-this is the most common entity confused with acute appendicitis.

Symptoms-Pain – the site or pain depends on the location of the calculus. Upper

ureteric calculus has pain in the loin. Ir radiates to the groin.

Lower uereteric calculi have pain in the right iliac fossa radiating to

the external genitalia or medial side of thigh.

Pain is severe enough to cause the patient to “roll-over” bed,

associated with sweating and vomiting.

USG abdomen- this reveals calculus and dilated pelvi-calyceal

system if there is associated hydro-uretero-nephrosis.

Treatment –

1. NSAIDS, antibiotics and adequate hydration.

2. Calcium-channel blocker, diuretics and alpha-blockers may be tried.

3. Lithotripsy may be done in resistant cases.

Diverticulitis:

-This refers to inflammation of the diverticula or out-pouchings

from the wall of large or small intestine.

The classical symptoms are left lower quadrant pain, fever and

leucocytosis.

Sometimes, right lower quadrant pain may occur in pre-dominant

right-colon involvement or a very redundant sigmoid colon.

Diagnosis –

CT abdomen is the investigation of choice. 5mm CT cuts are

accurate in diagnosing diverticulosis and in acute diverticulosis,

Treatment

-Uncomplicated diverticulosis may be treated with anti-biotics and

obsercation.

Complications of diverticulosis include perforation with peritoneal sepsis,

bleeding, obstruction, and fistula formation.

Perforation-surgically treated by diversion procedures.

Bleeding and obstruction- resection and anastomosis.

WOMEN OF CHILD-BEARING

AGE-1. PELVIC INFLAMMMATORY DISEASE:

Infection of the female genital tract including the uterus, ovaries,

fallopian tubes.

Associated with menorrhagia, lower abdominal pain and sometimes

fever, dyspareunia,intermensrual bleeding. Cervical motion tenderness and

leucorrhea are important distinguishing features.

2. OVARIAN CYST TORSION:

This is a gynecological emergency and can mimic as acute

appendicitis.

This happens when a large ovarian cyst undergoes twisting at its

pedicle and its blood supply is jeopardized.

This results in congestion and ischaemia of the ovaries and resultant

gangrene may also occur.

Symptoms-Sudden agonizing lower abdominal pain followed by vomiting,

tachycardia and fever.

Doppler USG: Investigation modality of choice. Lack of blood flow to

ovaries on Doppler confirms diagnosis.

Treatment:

This is surgical- laparoscopic ovarian cystectomy or oophorectomy

3. ECTOPIC PREGNANCY:

This presents as severe lower abdomen pain and tenderness in the

hypogastric region. The ectopic pregnancy site can be fallopian tubes(most

common), followed by ovaries and cervix.

Rupture of ectopic pregnancy into the abdominal cavity is a life

threatening complication and can result in severe blood loss and

hemorrghic shock.

Symptoms:

Pain over lower abdomen, pelvic pain or in low back. In ruptured

ectopic, patient may have shoulder pain, which is an ominuous sign cause

of diaphragmatic irritation.

There is associated tachycardia and pallor with signs of fall in BP

and cold peripheries –signs of hemorrhagic shock.

Cullen’s sign- discolouration of peri-umblical region may be seen.

Diagnosis –

Trans-vaginal USG demonstrates absence of gestational sac in the

uterus and presence of adnexal mass. These along with elevated beta-HCG

Treatment:

Unruptured ectopic pregnancy can be treated with methotrexate .

Ruptured ectopic pregnancy needs laparotomy and removal of

conceptus, ruptured part , securing complete hemostasis.

IN PREGNANCY:

The main problem of appendicitis in pregnancy is that the usual

symptoms of appendicitis such as nausea,vomiting, are also found in

pregnancy.

Also the tip of the appendix is shifted up by the gravid uterus and

the site of tenderness is usually at the right hypochondrial region by 5th

month. USG abdomen can be used safely to diagnose and in rare cases

MRI abdomen can also be used. As the chances of fetal loss increases with

peritonitis and sepsis, early surgical intervention is warranted in pregnancy

with appendicitis.

Second trimester of pregnancy is usually safe for surgical procedures.

OLD AGE:

Appendicitis in old age is difficult to diagnose because of atypical

Also appendicitis is thought of as a less likely diagnosis compared to

diverticulosis or colitis and hence missed often. There is also no

leucocytosis due to poor immunity. In elderly the cause for appendicitis

should also be sought as even a cecal or appendicular malignancy could

cause appendicitis hence imaging should be done in all cases.

APPENDICITIS IN INFANTS AND CHILDREN:

The diagnosis of acute appendicitis is difficult in infants and young

children because children are unable to give an accurate history, and acute

nonspecific abdominal pain is common in infants and children. Hence, the

diagnosis and treatment are often delayed, and complications develop. The

clinical presentation in children can be quite similar to nonspecific

gastroenteritis. Hence, the suspicion of appendicitis often is not entertained

until the appendix has ruptured.

Two thirds of young children with appendicitis have had symptoms

for more than 3 days before appendectomy.Because children often cannot

give an accurate history of their pain, the physical examination and other

aspects of the history must be relied on to make the diagnosis. Vomiting,

fever, irritability, flexing of the thighs, and diarrhea are likely early

complaints. Abdominal distention is the most consistent physical finding.

The incidence of perforation in infants younger than 1 year of age is

almost 100%, and although it decreases with age, it is still 50% at 5 years

of age. The mortality rate in this age group remains as high as 5%. In one

series, nearly 40% of children with complicated appendicitis had been

wrongly diagnosed with other causes of abdominal pain.

CLINICAL SCORING SYSTEMS FOR APPENDICITIS:

Acute appendicitis is essentially a clinical diagnosis. The sensitivity

and specificity of clinical methods have proven to be more than imaging

techniques.

To increase the diagnostic rate in appendicitis and reduce the rate of

negative laparotomies, several scoring systems have been developed.

Of these the Alvorado scoring system has been the most commonly

used scoring system and has a sensitivity of 80-85% in various studies.

It is a simple and useful diagnostic tool in adults in picking up cases

early and also reduces rate of negative appendectomies.When combined

with graded compression ultrasonography the diagnostic yield is still

ALVORADO SCORING:

The Alvorado scoring system was first developed by Alfredo Alvorado of Philadelphia in 1986 an Nazreth hospital on a cohort of 305 patients.

Symptoms score

Migratory right iliac fossa pain -1

Nausea/Vomiting -1

Anorexia -1

Signs

Tenderness in right iliac fossa -2

Rebound tenderness in right iliac fossa -1

Elevated temperature >37.5 C -1

Laboratory Findings

Shift to the left of neutrophils >75% -1

Leucocytosis >10,000 -2

The variables used in the scoring have can be remembered with the mnemonic MANTRELS. The scoring system has a maximum achievable score of 10.

Those with scores >7 – have high probability of appendicitis and are taken up for surgery. Those with scores 5-6 are subjected to further imaging and are subsequently either taken up for surgery or are observed depending on the imaging findings. Those with scores less than 4 are discharged and followed up as out patients.

It had the following statistics:

Sensitivity – 80-85%

Specificity –85-90%

Positive predictive value- 92-96% .

Management of Appendicitis based on modified Alvarado criteria

PEDIATRIC APPENDICITIS SCORE

It was first developed in 2002 by MADHAN SAMUEL of England.

It specifically addresses the symptomatology in children it was

developed because:

1.rebound tenderness as in Alvarado scoring is extremely painful in

children and can make them unco-operative, apprenhensive and hence

should not be used in children.

2.variables such as leucocytosis and polymorphonuclear

neutrophilia had good correlation and cough tenderness were assigned a

score of 2 each to improve accuracy when applied to children. Variables

such as cough tenderness and percussion tenderness are unique to children.

Children with score >8 were taken up for surgery and those with 4-7

were subjected to further imaging re-assessed with PAS and were either

taken up for surgery or were followed up as in-patients depending on

OTHER SCORING SYSTEMS:

The Tzanakis scoring system – This incorporated ultrasound , clinical

findings and lab investigations.

The Appendicitis inflammatory response score

Ohmann scoring

Lintula scoring system

Fenyo-lindbang.

Computerised algorithms were developed for quicker assessment of

SURGERY- OPEN APPENDECTOMY:

Incisions :

1. Mcburney incision- The incision is made obliquely, beginning

inferiorly and medially, and extending laterally and superiorly.

It should be 8 to 10 cm in length, with its most medial extent being

the lateral edge of the rectus muscle

2. Rockey Davis: The incision is made in a transverse direction, 1 to 3

cm below the umbilicus, and is centered on the midclavicular line.

3. Weir extension - medial extension of Rockey Davis.

4. Rutherford Morrisson- lateral extension of Rockey Davis

5. Lanz incision- incision along the langers lines.

STEPS:

With any one of the above incisions, skin and sub-cutaneous layers

are cut. The aponeurosis and muscles of the abdominal wall are split or

incised in the direction of their fibers and peritoneum is reached

After the peritoneum is opened, the appendix is identified by

following the anterior cecal taenia to the base of the appendix.

1. All three taeniae lead to and end at the base of the appendix.

2. The ileocecal junction can usually be identified, just below which is the base of the appendix.

After identification, the mesoappendix is clamped and cut and the base of the appendix is crushed, clamped and cut. Peritoneal lavage is given in abscess and drain is fixed.[3].

Clamping of the mesoappendix in appendectomy

This is done with curved clamps and the meso-appendix is either

Clamping and Ligation of the base of the appendix

LAPAROSCOPIC APPENDECTOMY:

The port sites are chosen as in the figure.

Usually one 10mm camera port and two 5mm working ports are used.

Pneumoperitoneum is attained to a pressure of about 14 mmhg.

Using Maryland forceps and non-toothed or toothed graspers,

mesoappendix is cauterized and base of appendix is ligated by endo-loop

technique.

The appendix is extracted through any of the 5mm ports.

Laparoscopic View of Appendix

The appendix is traced upto its base where it attaches to the cecum

MATERIALS AND METHODS

PATIENTS AND METHODS

About 50 patients presenting to general surgery and pediatric surgery

department in the age group 4-15 years with complaints of acute

abdominal pain were chosen for the study. Detailed history-taking and

complete physical examination were done. The patients were divided into

3 groups based on 8 variables in the PEDIATRIC APPENDICITIS

SCORING system into those with scores >8, those with scores between

5-7, and those with scores <4.

The first group was taken up for surgery,namely emergency

appendectomy either laparoscopically or by open technique. The second

group of patients with score 5-7 was subsequently subjected to

Ultrasonogram of the abdomen and were either taken up for surgery or

followed up as in-patients with periodic re-assessment. The third group of

patients with scores <4 were discharged and followed up as out- patients.

Children who had previous history of appendectomy and those less than 4

Intra-Op finding

Total Yes No

Pas Score

8-10

No. of children 36 1 37 % within Pas Score 97.3% 2.7% 100.0% % with Intra-Op finding 85.7% 14.3% 75.5%

5-7

No of children 6 6 12

% within Pas Score 50.0% 50.0% 100.0% % with Intra-Op finding 14.3% 85.7% 24.5%

Total No of children 42 7 49

% within Pas Score 85.7% 14.3% 100.0% % within Intra-Op finding 100.0% 100.0% 100.0%

Correlation Of Pas Score With Intra-OP Findings

97.3 % of the children with scores 8-10 had appendicitis intra-operatively and 50% of those with scores 5-7 had appendicitis as

Distribution of Incidence of Appendicitis among the study group

Children with scores>8 had 84% of the total no of appendicitis cases.

OBSERVATIONS AND RESULTS

Of the 50 children, 37 of them had PAS scores of 8 or more.12

children had scores between 5-7 and were subsequently subjected to USG

abdomen of which 6 of them had features suggestive of acute appendicitis

and were taken up for surgery. Of the remaining 6 children, 3 had other

mesenteric lymphadenitis and 3 had normal study. These patients were

managed conservatively and they responded well to conservative

treatment. There was 1child with PAS scores less than 4 and were

discharged and followed up.

The intra-operative findings of the 43 patients (37+6) and the

histopathology findings were taken as confirmatory evidence for

appendicitis. Of the 43 patients, 42 patients with scores >5, had inflamed

appendix and one patient with PAS score of 8 had normal appendix.

STATISTICS:

Age & sex:

The average age of children with appendicitis was 9.4 and the

average age in non-appendicitis group was 5.7 years. The sex ratio

INCIDENCE OF APPENDICITIS IN MALE AND FEMALE WITH

PAS SCORES

Male :female ratio was 1.8:1

0 5 10 15 20 25

<4-7 >7-10

DISTRIBUTION OF TYPES OF APPENDICITIS

Uncomplicated appendicitis was the most frequent presentation followed by perforated appendicitis and gangrenous appendicitis. One

case had early mass formation and appendectomy was done.

INFLAMMED APPENDIX

PERFORATED APPENDICITIS

NAUSEA VOMITING PYREXIA OF PAIN LEUCOCYTOSIS PMN NEUTROPHILIA RIF TENDERNESS COUGH TENDERNESS

DISTRIBUTION OF SYMPTOMS AND SIGNS

The order of diagnostic index of the variables was 1.percussion

tenderness(85.7%), 2.anorexia(83.7%),

3. Nausea/vomiting,(83.5%) 4.tenderness in the right lower

quadrant,(82%) 5. PMN neutrophilia (77.6%), 6.leucucytosis (77%), 7.,

8.migratory pain(76.9%), all with a p value of <0.01.

The mean temperature for pyrexia was 38.1 C +/- 0.5C, and the mean

leucocyte count was 13,300+/- 1,400.

The mean for PMN neutrophilia was 74%+/-7%.

After assigning the PAS scores the children were classified into

appendicitis(43) and non-appendicitis(7) groups. The appendicitis group

group were taken up for surgery and the non-appendicitis group were

either observed or discharged. The intra-op findings and HPE findings

were correlated and diagnosis confirmed and sensitivity, specificity and

positive predictive values were calculated.

From the table below the overall sensitivity of the test was 85.7%

and specificity was 97.3%. The positive predictive value was 97.3% but

HPE Total Appendiciti Normal

Pas Score 8-10 No of children 36 1 37 % within Pas Score 97.3% 2.7% 100.0% % within HPE 85.7% 14.3% 75.5%

5-7 No of children 6 6 12

% within Pas Score 50.0% 50.0% 100.0% % within HPE 14.3% 85.7% 24.5%

Total No of children 42 7 49

% within Pas Score 85.7% 14.3% 100.0% % within HPE 100.0% 100.0% 100.0%

Table correlating PAS SCORE with HPE report

97.3% of children with scores 8-10 had appendicitis confirmed on

DISCUSSION:

DEFINITION OF VARIABLES AND PARAMETERS:

Pyrexia – temperature > 37 .5 C

Leucocytosis- WBC> 10,000

PMN neutrophilia- >75 % of neutrophil count.

Migratory RIF pain- pain initially at the peri-umblical region later on

migrating to right-iliac fossa

Percussion tenderness- tenderness over right iliac-fossa to gentle

percussion

Cough tenderness- tenderness over RIF on asking the child to cough.

Anorexia – decrease in intake of food after the onset of pain.

USG findings suggestive of appendicitis- dilated, aperistaltic,

non-compressible structure in the right iliac-fossa.

Thus, the PEDIATRIC APPENDICITIS SCORING SYSTEM has high

sensitivity,specificity, and positive predictive value and poor negative

DR.MADHAN SAMUEL et all, and the study done by Ran Goldman in

“Prospective Validation of the Pediatric Appendicitis Score” by RAN D.

GOLDMAN, MD, SUSAN CARTER, BSC, DEREK STEPHENS, MD

and “ The prospective validation of PAS on Canadian population by Maala

Bhatt. The statistical inferences were comparable to the original study

CONCLUSION

This study shows that PEDIATRIC APPENDICITIS SCORING

SYSTEM is a useful diagnostic tool in the diagnosis of acute appendicitis

in children. This clinical scoring system can be used in remote areas where

other imaging modalities are unavailable and also can be used in the same

1. SABISTON TEXT BOOK OF SURGERY-18TH EDITION.

2. SKANDALAKIS –SURGICAL ANATOMY

3. SHACKELFORDS TEXTBOOK OF SURGERY OF THE

ALIMENTARY TRACT.- 6TH EDITION.

4. PEDIATRIC SURGERY by PURI AND HALLWORTH

5. BAILEY and LOVE TEXTBOOK OF SURGERY

6. ATLAS OF GI SURGERY by CAMERON.

7. Prospective Validation of the Pediatric Appendicitis Score RAN D.

GOLDMAN, MD, SUSAN CARTER, BSC, DEREK STEPHENS,

MD, ROULA ANTOON, MD, WILLIAM MOUNSTEPHEN, MD,

8. Utility of a scoring system in the diagnosis of acute appendicitis in

pediatric age. A retrospective study. Minerva Chirurgica

2002;57:341-6.

9. Bond GR, Tully SB, Chan LS, Bradley RL. Use of the MANTRELS

score in Childhood appendicitis: a prospective study of 187 children

with abdominal pain. AnnEmerg Med 1990;19:1014-8.

10. Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002;37:

the diagnosis of appendicitis Ped Emerg Care 2004;20:795

[Abstract]

12. Alvarado scoring - practical score for the early diagnosis of acute

appendicitis. Ann Emerg Med 1986;15:557-64.

13. Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation

of the Alvarado score in acute appendicitis. J R Soc Med

1992;85:87-8.

14. Lamparelli MJ, Hoque HM, Pogson CJ, Ball AB. A prospective

evaluation of the combined use of the modi ed Alvarado score with

selective laparoscopy in adult females in the management of

suspected appendicitis. Ann R Coll Surg Engl 2000;82:192-5.

15. Ramirez JM, Deus J. Practical score to aid decision making in

• NAME : SL. NO:

• AGE /SEX:

• ADDRESS WITH CONTACT NUMBER:

• IP NO:

• DATE OF ADMISSION:

• DATE OF SURGERY:

• DATE OF DISCHARGE:

HISTORY OF PRESENTING ILLNESS:

PAIN ABDOMEN:

•

Site--•

Duration-•

Nature-• Aggravating/relieving

factors-• Radiation of

pain-• H/O NAUSEA/VOMITING IF ANY:

• H/O FEVER, IF ANY:

Whether a known case of Asthma/TB/epilepsy/cardiac

illness

H/O SIMILAR EPISODES IN THE PAST, IF ANY:

H/O SURGERIES IN THE PAST, IF ANY

H/O MAJOR ILLNESS/ HOSPITAL ADMISSIONS, IF ANY

PERSONAL HISTORY:

Whether a smoker or an alcoholic,

FAMILY HISTORY:

TREATMENT HISTORY:

CLINICAL EXAMINATION:

GENERAL EXAMINATION:

SYSTEMIC EXAMINATION:

CVS

RS

PER ABDOMEN PALPATION

RIF TENDERNESS

PERCUSSION TENDERNESS

CLINICAL DIAGNOSIS:

INVESTIGATIONS:

• USG ABDOMEN AND PELVIS

• ROUTINE INVESTIGATIONS(CBC,RFT,CXR,ECG)

• OTHER INVESTIGATIONS(IF ANY):

FINAL DIAGNOSIS:

SURGERY DONE:

INTRO-OP FINDINGS:

S.

NO

NAM

E

AGE SEX _I.P.No

N AU SE A/ VOM IT ING A NOR E XI A F EV ER M IG R A T IO N o

f P

AI L EU C O C YTO S IS NE UTR P H IL IA

RIF TEN

D ERNE SS PERC USS IO N TE N DER P AS SC OR E U SG INT RA -OP F IND IN HPE

1 JANARTHANAN 9 M 77178 1 1 - - 1 1 2 2 8 - INFLAMMED TIP OF APPENIX F/S/O

APPENDICITIS

2 KEERTHAN 12 M 77720 1 1 1 - 1 1 2 2 9 - INFLAMMED

APPENDIX

F/S/O APPENDICITIS

3333 3 3 ARUN 11 M 76587 - 1 - 1 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

4 SWETHA 4

½

F 78244 1 1 - - 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

5 HARIHARAN 8 M 79674 - 1 1 - - - 2 2 6 MESENTRIC LYPHADENITIS -

6 SHAIK MOHAMMAD

12 M 79996 1 1 1 - 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

7 IBRAHIM 6 M 80193 1 - 1 - 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

8 MUKESH 9 M 35007 1 1 1 - - - 2 - 5 NORMAL STUDY -

9 PRAKASHI 9 M 82854 1 1 - 1 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

10 RITHICK KUMAR

11 M 38318 - 1 1 - 1 - 2 - 5 RIF PROBE TENDERNESS INFLAMMED APPENDIX F/S/O

APPENDICITIS

11 MOHAMMAD

YASIM

13 JACKULIN 11 F 39838 1 1 1 1 - 1 2 2 9 - PERFORATED APPENDIX F/S/O APPENDICITIS

14 LAKSHMANAN 7 M 82554 1 1 1 1 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

15 VALARMATHI 9 F 83830 1 1 - 1 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

16 PRADEEP 8 M 40041 1 1 1 - 1 1 2 2 8 - Normal study Normal study

17 SUMAIYA BANU 12 F 84038 1 1 - 1 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

18 VENKATESH 9 M 85584 1 - - 1 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

19 SURYA 12 M 84452 1 1 - 1 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

20 SHRUTHI 7 F 84559 1 1 - - - - 2 2 6 F/S/O APPENDICITIS INFLAMMED APPENDIX F/S/O

APPENDICITIS

21 SARATHY 9 M 85719 1 1 - 1 1 - 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

22 PAVITHRA 12 F 85314 1 1 - 1 1 1 - - 8 - -

23 VICTOR 11 M 85613 1 1 1 - 1 1 2 2 9 - EARLY APPENDICULAR

MASS

F/S/O APPENDICITIS

24 MADHAVAN 7 M 54755 1 1 1 1 1 1 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

25 GOKUL RANI 6 F 86288 - 1 1 - 1 - 2 2 9 F/S/O APPENDICITIS INFLAMMED APPENDIX F/S/O

APPENDICITIS

26 SOMA 9 F 86286 1 - - 1 1 1 2 2 8 - Gangrenous appendicitis F/S/O

APPENDICITIS

29 NARMADHA 4 F 86426 1 1 1 - 1 1 2 2 9 - PERFORATED APPENDIX F/S/O APPENDICITIS

30 VARUN 11 M 57775 - 1 - 1 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

31 SANGEETHA 10 F 86623 1 - 1 - - 1 2 - 5 NORMAL STUDY -

32 RAMYA 12 F 86772 1 1 - 1 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

33 SUKUMAR 8 M 66020 - 1 - - 1 1 2 2 5 F/S/O APPENDICITIS INFLAMMED APPENDIX F/S/O

APPENDICITIS

34 SIRAJ 10 F 59361 - 1 - 1 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

35 LOGESH 5 M 66217 1 1 - 1 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

36 MANIKANDAN 7 M 66196 - 1 1 1 1 1 2 2 9 - PERFORATED APPENDIX F/S/O

APPENDICITIS

37 AJAY 9 M 66534 1 1 - - 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

38 DEEPAK 10 M 66644 1 - - 1 - - 2 2 6 F/S/O APPENDICITIS INFLAMMED APPENDIX F/S/O

APPENDICITIS

39 VASANTH 11 M 66848 1 1 - - 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

40 SOFIA 10 F 66900 1 1 1 - 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

41 ADHILAKSHMI 11 F 11111 1 1 - 1 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

42 HELAN 9 F 67201 1 1 1 - - - 2 - 5 NORMAL STUDY -

-43 SRI DEVI 10 F 12084 - 1 - 1 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

45 KRITHIKA 9 F 67596 1 - 1 - 1 - 2 - 5 MESENTRIC ADENITIS -

-46 ABILASH 12 M 67709 - 1 - 1 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

47 MONISHA 9 F 68714 1 1 - 1 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

48 GOUTHAM 10 M 67902 - 1 - - 1 - 2 2 6 F/S/O APPENDICITIS INFLAMMED APPENDIX F/S/O

APPENDICITIS

49 EZHILARASI 5 F 68802 1 1 - 1 1 1 2 2 9 - INFLAMMED APPENDIX F/S/O

APPENDICITIS

50 SOLOMON 9 M 70154 1 - - 1 1 1 2 2 8 - INFLAMMED APPENDIX F/S/O